cholera, quarantine preventive system, …...cholera, quarantine andthe english preventive system...

Medical Historv, 1993, 37: 250-269.

CHOLERA, QUARANTINE AND THE ENGLISHPREVENTIVE SYSTEM, 1850-1895

by

ANNE HARDY *

Cholera is popularly remembered as the disease which made the nineteenth century itsown, appearing from obscurity to devastate Europe repeatedly in the years between 1830and the 1920s. Six pandemics spread fear and alarm, terrible illness and horrible death,across the Continent before 1900,1 distorting the true demographic significance of thedisease and deflecting both contemporary and historical attention from the indigenous"diseases of society".2 Epidemic cholera had its origins in India; for Europe it was only aninvader, as plague had been originally. In its status as invader, and in the magnitude of itsgeographical range, lay its impact and its influence on nineteenth-century society.More than thirty years ago, Asa Briggs drew attention to the international significance of

cholera, and stressed the need for comparative examination of responses to cholera indifferent countries and in different epidemics.3 Although the disease has since attractedmuch historical attention, this has been largely concentrated on individual epidemics(notably that of 1830-32), and on contemporary debates about the causes of the disease.4It is only recently that studies which recognize and stimulate consideration of the widerEuropean cholera experience of the period 1830-1900 have begun to appear, and the laterhistory of the disease in Europe remains largely unexplored.5 Both the pattern of localresponses to the later outbreaks, and the processes involved in cholera's gradual withdrawalfrom the Continent, merit investigation, as does the wider context of the development of

* Anne Hardy, MA, D.Phil., Wellcome Institute for the History of Medicine, 183 Euston Road, LondonNW I 2BE.

Different authorities, with differing perspectives, give varying dates forthecholerapandem-ics. From the globalperspective, dates are given as 1817-23; 1826-37; 1846-62; 1864-75; 1883-94; 1899-1923: William Topleyand Graham Wilson, Principles of bacteriology, virology and immunity, vol. 3, 7th edition, ed. G. R. Smith,London, Edward Arnold, 1984, p. 446. From the European perspective, the pandemic dates commonly acceptedand adopted here are those given by Richard Evans, 1830-2, 1847-9, 1853-4, 1865-6, 1873, 1884, 1892-3.Contemporaries sometimes took a different view, giving the dates as 1830-7; 1847-56; 1865-73; 1884; 1892:Philippe Hauser, Le cholera en Europe, Paris, Societe d'editions scientifiques, 1897.

2 Margaret Pelling, Cholera, fever and English medicine 1825-1865, Oxford University Press, 1978, pp. 3-4.3 Asa Briggs, 'Cholera and society in the nineteenth century', Past and Present, 1961, 19: 76-96.4 Among a large literature see, Michael Durey, The return of the plague: British society and the cholera,

1831-32, Dublin, Gill and Macmillan, 1979; R. J. Morris, Cholera 1832. The social response to an epidemic,London, Croom Helm, 1976; Pelling op. cit., note 2 above; W. Luckin, 'The final catastrophe-cholera inLondon, 1866', Med. Hist., 1977, 21: 32-42; Franqois Delaporte, Disease and civilisation: the cholera in Paris1832, Cambridge, MIT Press, 1986; Roderick E. McGrew, Russia and the cholera, 1823-1832, Madison andMilwaukee, University of Winsconsin Press, 1965; Richard J. Evans, Death in Hamburg: society and politics inthe cholera years, Oxford University Press, 1987.

'See e.g., Richard J. Evans, 'Epidemics and revolutions: cholera in nineteenth-century Europe', Past andPresent, 1988, 120: 123-46; F. M. Snowden, 'Cholera in Barletta 1910', Past and Present, 1991, 132: 67-103.

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Cholera, quarantine and the English preventive system

public health programmes in the different European countries. Although this paper focuseson the English experience of cholera after 1850, and on the development by the Englishhealth authorities of a system for excluding the disease from the country, this local historyhas a more than local significance.6 As a public health problem, cholera was recognized tobe of international dimensions by 1850, and, in the search for a coherent internationalpreventive policy in the decades after 1850, the cholera experience of England was to provecrucial.The last English cholera epidemic occurred in 1866, after which England was singularly

successful in excluding the disease. The traditional European response to invading infectionswas quarantine: cholera and the English example between them ended that tradition.Quarantines were a marked feature of government responses to the first and secondpandemics; yet they transparently failed to prevent outbreaks of cholera, and were oftenabandoned.7 It was this failure that stimulated the first attempts to achieve an internationalpolicy for limiting the disease. The first International Sanitary Conference was convened atParis in 1851 to examine Europe's position in respect of cholera, and to try to establish aninternational consensus on enforcing broadly uniform precautionary measures.8 It was thefirst of a series of such conferences, most of which foundered on the issue of trade,quarantine and international shipping. The majority of European countries continued tofavour quarantine as the means of preventing the entry of sea-borne cholera, but Britain wasadamantly opposed to any restriction on the freedom of trade. While medical men anddiplomats struggled to reach agreement at repeated international conferences-atConstantinople in 1865, Vienna in 1874, Rome in 1885-the English preventive authoritiesevolved and perfected a system of sanitary surveillance coupled with detailed preventivemeasures (isolation and disinfection), which appeared to meet the challenge of importedcholera effectively. The British success in avoiding epidemic cholera after 1870, togetherwith increasing familiarity with the causes and movements of the disease, were influentialin changing attitudes among European observers. At the Conference of Venice (1892) andDresden (1893), the value of the English system was finally acknowledged, and itstechniques adopted as the basis of international preventive action.9

Britain's position as an island nation extensively involved in international trade was acrucial determinant in the development of her cholera exclusion policy. Politically andeconomically committed to freedom of trade, the country had to devise measures other thanquarantine for the exclusion of imported infectious disease.'0 The absence of epidemiccholera from the country in the decades after 1870 has often been attributed to sanitary

6 This account of preventive approach to cholera as an invader complements and extends my discussion of thepreventive authorities' contribution to controlling the indigenous infectious diseases: Anne Hardy, The epidemicstreets: infectious disease and the rise of preventive medicine, 1856-1900, Oxford University Press, in press.

7 Evans, op. cit., note 4 above, p. 245.8 A briefaccount ofthe International Sanitary Conferences is given in Hauser, op. cit., note 1 above, ch. 12. For a

more extended treatment see Norman Howard-Jones, The scientific background of the international sanitaryconferences, 1851-1938, Geneva, World Health Organisation, 1975. For the problems posed by India and theIndian trade see Mark Harrison, 'Quarantine, pilgrimage, and colonial trade: India 1866-1900', Indian Econt.Soc. Hist. Rev., 1992, 29: 117-44.

9 Hauser, op. cit., note I above, pp. 534-8."' ForBritish quarantine see Charles F. Mullett, 'A century ofEnglish quarantine, 1709-1825', Bull. Hist. Med.,

1949, 23: 527-45; J. C. McDonald, 'The history of quarantine in Britain during the 19th century', Bull. Hist.Med., 1951, 25: 22-44.

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improvement;" indeed, Michael Durey has convincingly argued that the "ideal" conditionsfor the spread of cholera within the community had begun to disappear soon after theoutbreak of 1847-48.12 While there is no doubt that improving sanitary conditions andwater supplies made a large contribution to England's freedom from cholera, the number ofimported cases after 1870, and the persistence of waterborne typhoid in various parts of thecountry into the 1890s, indicate that possibilities for the epidemic extension of choleracontinued to exist. Closer examination of the circumstances of the European choleravisitations after 1866, and of the development of English sanitary legislation, suggests thatgood fortune and an alert public health organization played a significant part in Britain'svirtual freedom from cholera.

CHOLERA OBSERVEDThe mid-Victorian public health organization was empirical in its methods, and

observation of the broad epidemiological behaviour of cholera, as revealed by its patterns ofdissemination across Europe, was central to the development of England's defences againstthe disease. Already by the 1850s, the European manifestations of cholera were beingstudied with interest by English sanitarians trying to predict the likely assaults of the diseaseon their own country. The pandemics of 1830, 1846 and 1853 suggested that it movedoutward from its homeland by successive steps, following overland trade routes and lines ofcommunication.'3 It would only reach England in the second year of a European visitation,although minor outbreaks generally occurred in the autumn of the first year, heralding amajor epidemic in the following summer. The principal danger for England lay in the arrivalof the disease at the Baltic ports, especially Hamburg: in 1832, 1848, and 1854, theepidemic outbreak of cholera at Hamburg was rapidly followed by the appearance of thedisease in seaports on the east coast of England.'4

Season was also important in timing the arrival of epidemic cholera; August andSeptember were the months of most danger in England.'5 The cholera vibrio is notoriouslysensitive to heat and humidity. It can survive for days or even weeks in moist linen, but onlyfor a few hours when exposed in hot dry conditions. It can also live in water for variablelengths of time depending on the pH factor, salinity and degree of contamination with otherconditions. In nineteenth-century Europe, the long-term pattern, and local and seasonaldistribution of the disease were partly determined by climatic variation, 16 and this seasonalfactor was in some degree recognized by contemporaries. By the mid- I 850s, public healthobservers, tracing the movement of the disease across Europe, were able to view itsapproach with a certain dispassion. Until it reached the Baltic, there was little to fear; if itreached Hamburg in the late autumn, as it often did, there would be no major Englishoutbreak until the following summer, when conditions for its resurgence and onward marchwere once again favourable.

" For example, Anthony Wohl, Endangered lives: public health in Victorian Britain, London, EdwardArnold, 1983, p. 124. F. B. Smith, The people's health 1830 to 1910, London, Croom Helm, 1979, p. 233, drawsattention to the part played by "strict national quarantine".

' Durey, op. cit., note 4 above, p. 204.13 Hauser, op. cit., note I above, p. 533.'1 Lancet, 1857, ii: 374."Ibid., 1894, ii: 444.16 Topley and Wilson, op. cit., note I above, pp. 449, 451.

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Growing familiarity with the behaviour of cholera bred little immediate complacency,however. More than any other decade, the 1850s were haunted by the disease. Theepidemic of 1853-4, following so close upon the heels of that of 1848-9, awoke fears thatthe disease might become indigenous, or at least that the intervals between epidemicswould shorten still further.'7 The presence of cholera in the Crimea, at a time whennewspaper correspondents were revealing the horrors of the Crimean War to the Britishpeople, helped to keep it in the public eye. When the disease arrived at the Baltic ports andHamburg in October 1857, the General Board of Health issued detailed preventive advice;a small outbreak at West Ham was widely regarded as a warning to expect a majorepidemic in 1858.18 The Lancet fulminated against the state of the Serpentine, and urgedpreventive action: "There are six clear months before us for sanitary improvements-sixmonths for organising a thoroughly efficient staff of officers, and for pre-arranging aconcerted method of action".19

Yet there is little evidence from the reports of London's newly appointed medicalofficers of health of any specifically cholera-induced sense of urgency in their work, whilethe reports of the new Medical Department of the Privy Council focus on smallpox anddiphtheria in these years. Perhaps it was as well that the expected epidemic did notmaterialize in 1858. Possibly because of the great heat and drought of that summer-it wasthe year of the Great Stink in London-cholera retreated from the southern Balticseaboard, to ravage instead Stockholm and St Petersburg.20 In 1859, however, it returnedto Hamburg, and an English epidemic was confidently expected: cholera, remarked theLancet, "now seems to become a periodical scourge to this country"'.21 A number of caseswere introduced into London and Tyneside from Hamburg,22 but, again perhaps becauseof adverse weather conditions, there was no extension of the disease.

Throughout this anxious decade, the prevailing preventive attitude towards cholera wasdetermined by pragmatism.23 Nothing certain was known of the immediate orcircumstantial cause of the disease; the waterborne theory of cholera transmissionreceived wide publicity, but little wholehearted acceptance. Debate about the true cause ofcholera continued, with some espousing miasma theory, some water theory, and many amiddle position, which took account of both. The reactions of the medical community tothe threat of epidemic cholera in the autumn of 1857 reflected this diversity of opinion.24There were, however, signs of a new confidence in dealing with cholera among themedical community. This was based not on any improved understanding of the etiology ofthe disease, but rather on past experience and on improved sanitary organization. Despite

7 Lancet, 1858, i: 72.8 Ibid., 1857, ii: 374-5, 369, 478.'9 Ibid., 367, 369, 478.2() Ibid., 1858, ii: 41, 363, 660. For the Great Stink see Carleton B. Chapman, 'The year of the Great Stink',

Pharos, July 1972, pp. 90-103.21 Ibid., 1859, ii: 137.22 Ibid., 137-8, 169, 226.21 Pelling, op. cit., note 2 above, p. 310, argues that the "main product of mid-nineteenth-century epidemiology

was a kind of compromise .. an intelligent position consistent with interest, experience and methodology." Iendorse this view. See also Christopher Hamlin, 'Predisposing causes and public health in early nineteenth-century medical thought', Soc. Hist. Med., 1992, 5: 43-70.

24 Lancet, 1857, ii: 374.

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the little evidence of cholera-specific sanitary activity, the Lancet, for example, exhibitedconsiderable faith in the efficacy of London's newly appointed medical officers of health:

At last a vigorous and vigilant administration has been organised in the Boards andOfficers of Health, called into action by the Metropolis Local Management Act, forprotecting the population of London against future assaults [of cholera]. That ourdefensive provisions in the capital are immeasurably superior to those of any formerperiod cannot be doubted.25

This judgment was undoubtedly based on the prescription of general sanitaryimprovement: urging the importance of preparation for the expected major outbreak of thedisease in 1858, the journal's emphasis was firmly on sanitary improvement, efficient staffand a pre-determined course of action.26 Local activity, local improvement, were still seenas the key to successful prevention.

THE LESSONS OF 1866By contrast with the 1850s, the explosion of pandemic cholera in the 1860s was met by

an established sanitary organization, with nearly ten years of work behind it. In thoseyears, considerable improvements had been effected in both the environment and publichealth organization of London and other large cities: in 1864, the Registrar-Generalthought the great towns in a far better condition than ever before to encounter cholera.27Against this background, the English sanitary authorities viewed the movement of choleraacross the continents of Asia and Europe from the 1860s with increased confidence; aconfidence founded on the basis of accumulated evidence, and experience, of cholera as anassociate of insanitary conditions.

Cholera, however, retained the ability to surprise. In 1865, for the first time, it chose toapproach Europe not by the recognized land route, but by sea. The disease broke out inEgypt in June 1865, and this, together with an unusual prevalence of diarrhoea in London,aroused considerable alarm in England.28 By mid-July the "epidemic tension" was high,and quarantine measures were being debated.29 While the government resolutely stated itsopposition to quarantine, the alertness of the Medical Department and the General-Register Office to foreign epidemics produced a positive response to the threat of cholerain 1866. John Simon traced the movement of the disease across the European continentthroughout 1865.30 Reporting the outbreak of cholera at Rotterdam on 21 April 1866, the

2' Lancet, 1857, ii: 367.26 Ibid., 369, 396.27 Annual report ofthe Registrar-General (henceforth RGAR), Parliamentary Papers (henceforth PP) 1867 xvii,

p. 49.2X Briggs, op. cit., note 3 above, p. 87, states that cholera entered Britain from Egypt in 1866. This is not strictly

true, although the case is also made by Ernest Hart, 'Cholera and our protection against it', Nineteenth Century,1892, 188: 638. There is no suggestion in John Netten Radcliffe's report that the two cases which might haveinfected the river Lea originated in Egypt; the first case was employed in a local brush manufactory, and it ispossible that imported raw materials were contaminated. Radcliffe's findings clearly indicate that cholera wascoming into Britain from many of the major Channel and Baltic ports (Rotterdam, Antwerp and Hamburg, forexample) throughout May, June and July, and Radcliffe himself evidently considered the European connection tobe the important one: Medical Officer's annual report to the Privy Council later to the Local Government Board,(henceforth MOARPCLGB) 1867 xxxii, Appendix 7f, pp. 265-7.

29 Lancet, 1865, ii: 99-100.31 MOAR to PC, PP 1867 xxxvii, Appendix 7, pp. 264-5.

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Lancet gave thanks for the "enlightened measures" of the Medical Department of the PrivyCouncil, through which, "we may anticipate greater success in warding off this terribleenemy ... owing to the extension of sanitary improvements".3' In the event, the 1866epidemic proved the cholera defences of the nation, and of London in particular, to bedeficient in two vital respects: the cleanliness of water supply and the regulation ofshipping.32 The medical authorities' experience of the 1866 cholera epidemic wasimportant in several respects. It established the formula for dealing with local choleraoutbreaks; a formula which was to be reissued at every cholera scare until the end of thecentury. It confirmed to many the significance of the quantity and quality of water supply,and resulted in the eventual extension of constant supplies throughout London. Importedsimultaneously with the cattle plague which devastated British herds in the summer of1866, cholera pointed to the role of the country's ports in admitting communicable diseaseinto the country. And finally, the 1866 epidemic increased the confidence of the medicalcommunity in their own ability, through sanitary improvement and rigorous sanitarysupervision, to limit outbreaks of the disease where it was not transmitted through water. Itwas, however, the attention paid to quality of water supplies and the regulation of shippingin the years after 1866 that led to the country's virtual freedom from cholera in the lastthree decades of the century.

Doubts and difficulties continued, however, to surround issues of water purity beforethe twentieth century.33 This meant that the first element in the country's defences againstcholera was her shoreline, the point of entry for the disease. Uncertain of the exactrelationship between water and the transmission of cholera, and also of the exactefficiency of existing methods of water purification, English resistance to cholera after1870 concentrated on safeguarding against the importation of cases. In this respect, theexperience of 1866 was critical: it resulted in the refocusing of the English preventiveeffort. Cholera was no longer viewed as a local problem, but as one which must be met bya broadly based preventive scheme which took account of its status as invader, and of itsmeans of international transmission.

PORT SANITARY AUTHORITIESThe cardinal importance of preventing the entry of dangerous communicable diseases

into the country was recognized by the creation of a whole new division to the country'spreventive organization, the Port Sanitary Authorities. For commercial and politicalreasons, the introduction of quarantine for shipping was out of the question.34 Theexperience of 1866, however, convinced the medical community that some form of controlon the entry of vessels from areas known to be affected by communicable diseases was an

"' Lancet, 1866, i: 464.32 For the history of the 1866 outbreak in London see Luckin, 'The final catastrophe', op. cit., note 4 above, pp.

32-42; idem, Pollution and control: a social history of the Thames, Bristol, Adam Hilger, 1986, chapter 7.33 For progress and problems with water supplies see Durey, op. cit., note 4 above, p. 204; Anne Hardy, 'Water

and the search for public health in London in the eighteenth and nineteenth centuries', Med. Hist., 1984, 28:250-82, p. 273; idem, 'Parish pump to private pipes: London's water supply in the nineteenth century', Livingand dying in London, Med. Hist., Supplement no. I 1, London, WIHM, 1991, pp. 76-93; Christopher Hamlin, Ascience of impurity: water analysis in nineteenth-centurvy Britain, Bristol, Adam Hilger, 1990; A. C. Houston,Studies in water supply, London, Macmillan, 1913, chapter 7.

34 See Mullett, op. cit., note 10 above, pp. 527-45; McDonald, op. cit., note 10 above, pp. 22-44.

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essential preventive measure. Already in 1858, the Epidemiological Society had beenunanimous that medical inspection should be introduced for steamers and other vesselstrading between Britain and other countries, particularly during the prevalence ofepidemics.35 The importations of 1866 served to re-emphasize the lesson: as John Simonobserved emphatically, "contagions current on the Continent of Europe must be deemedvirtually current in England".36 Some attempt was made in the Sanitary Act 1866 toprovide for the "shipping difficulty",37 but when cholera became epidemic in EasternEurope in 187 1, and there were serious fears of its importation, the Medical Departmenttook action. The authorities of the 48 leading ports were prepared for preventive action bythe Department's inspectors with such success that a system of local port defence wasgiven statutory confirmation in the following year.38The establishment of the Port Sanitary Authorities in 1872 finalized the structure of the

British preventive organization. The system offered both protection against the import ofcommunicable disease and the regulation of sanitary conditions within ports. In the Port ofLondon, the sanitary regulation of shipping was finally put on a regular footing, havingbeen virtually absent in the past. Some accommodation for sick seamen had long beenprovided by the Seamen's Hospital Society,39 and during the cholera epidemic of 1866this organization proved invaluable, not only in providing hospital facilities for seamenand coastal traders, but also in undertaking a ship-to-ship visitation.40 The sanitaryconditions revealed by this inspection were not encouraging. The problem lay not so muchin the ocean and coastal traffic of the port as in its regular residents. As the Lancet phrasedit, no class was so totally unprotected by "even the ghost of a sanitary regulation".4'Between London Bridge and Blackwall hundreds of barges lay moored in tiers three orfour deep, without either sanitary facilities or water supplies. The barges themselvesprovided only a couple of tiny cabins, in which whole families dwelt, and wereill-ventilated, poorly lit and insanitary; nearly all the cholera cases dealt with on theBelleisle hospital ship in 1866 came from this quarter.42A leading part in the campaign for the greater regulation of shipping was played by

Henry Letheby, Medical Officer of Health for the City of London. Letheby had for sometime been concerned about sanitary conditions in the Port,43 and the shipping provisions ofthe 1866 Sanitary Act stimulated him to arrange the appointment of a special officer toinspect shipping within the City's jurisdiction, on the north side of the Thames betweenthe Temple and the Tower. The City was the only London authority to take such a

" Lancet, 1858, i: 72.-36 MOARPC, PP 1866 xxxiii, p. 43.37 Sanitary Act 1866,29& 30 Vict. c. 90, secs. 29,30. Nuisance authorities, with Privy Council permission, were

allowed to regulate for the removal to hospital and maintenance there for as long as necessary any personssuffering from dangerous or infectious disorders brought into their districts by any ship or boat.

3x Royston Lambert, Sir John Simon, 1816-1904, and English social administration, Bristol, McGibbon andKee, 1963, pp. 435-6; Public Health Act 1872, 75 & 76 Vict. c. 79, sec. 20. See also Lancet, 1871, ii: 227, 326.

3' The Seamen's Hospital Society was responsible for the Dreadnought Hospital, Greenwich, established in1763. The Hospital was taken over by the NHS in 1948, and was closed in 1988. In 1866 the Society borrowedthe Belleisle from the Government as a floating hospital ship for cholera cases.

40 Lancet, 1866, i: 527; ibid., 1871, ii: 326.4' Ibid., 1866, ii: 130.42 Ibid.43 Lancet, 1871, ii: 326. See also Letheby's annual reports, and his 'Report on the Sanitary Inspection of

Shipping', 1868.

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measure, although the medical officers of both the Dreadnought Hospital and the Customswere by now convinced of the need for action-uniform action-along the whole courseof the river, especially in respect of the sanitary condition of shipping and the import ofinfectious disease." The section of the Port supervised by the City's inspector representedonly a tiny fraction of the total problem, and when cholera threatened in 1871, the PrivyCouncil Medical Department organized a supervisory authority which represented jointlythe various sanitary authorities which abutted on the Thames.45 In practice, thearrangement did not prove fully satisfactory, as most of the authorities were reluctant tofinance the necessary measures.46 It was perhaps for this reason that under the PublicHealth Act, 1872, the City was constituted the sole sanitary authority of the Port ofLondon, with all expenses of the port sanitary authority to be paid for from corporatefunds.47The first Medical Officer for the Port of London was Harry Leach, whose first

appointment had been as assistant physician at the Dreadnought Hospital, and who hadhad charge of the Belleisle and organized the sanitary inspection of shipping during thecholera crisis of 1866. A young man of tact and good temper, boundless energy andundaunted courage in the face of difficulties, Leach took up his duties in July 1873.48 Thetask which he faced was formidable. London was then "the wealthiest, most populous, andworst arranged port in the world".49 The Port of London sanitary district extended fromTeddington Lock to the North Foreland, was 88 miles long, and included 8 sets of docksand 13 creeks. It was surrounded by 46 waterside authorities, each of which had hadriparian powers in the Port before 1872, but which now had no sanitary powers below theTrinity High Water mark within the limits of the Port. Six other bodies were moreparticularly concerned in the general business of the Port: the Customs; the MarineDepartment of the Board of Trade; Trinity House; the Thames Conservancy; the Thamescontingent of the Metropolitan Police; and the dock companies. It was estimated that25,000 vessels entered and left the Port yearly, while there were 2,300 sailing and 4,000"dumb" barges on the Thames, the latter alone containing a population of about 15,000.50Compared with the sanitary supervision of even a populous London parish, the sanitarymanagement of the Port of London was no light task.

Although sanitary conditions within the ports were a subject of daily concern, thegreatest vigilance of the English port sanitary authorities was directed towards the importof communicable and infectious disease. Disease prevention policy in the first ten years ofthe port authorities' existence was to a large extent exploratory and experimental, but thepowers which the port authorities exercised in cases of communicable disease were

4' Henry Letheby, 'Report on the sanitary condition of shipping', 1868, pp. 6, 9.45 Lancet, 1871, ii: 326, 343, 413, 448.46 For Letheby's complaints see MOAR, City of London, 1870-1, p. 50; Lancet, 1871, ii: 645.47 Public Health Act, 1872, sec. 20.4' Leach died in harness, of tuberculosis in November 1879. He was succeeded by another strong and genial

personality, William Collingridge, who served the City Corporation for twenty years as Port Medical Officer, anda further twelve as MOH for the City.

4' Lancet, 1871, ii: 270.5 Half yearly report of the Medical Officer (henceforth MOHYR), Port of London, December 1873, p. 4;

Lancet, 1871, ii: 270, 326.

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already greater in several respects than those of their mainland colleagues. Under theQuarantine Act, 1825, all infectious disease on board vessels entering port, with theimportant exception of coasters, was to be reported to the Customs, who detained suchvessels until their release was recommended by the officer of the local sanitary authority.5'The Public Health Act, 1875, made possible the compulsory removal to hospital of everypatient suffering from an infectious disease on shipboard, and enabled the port sanitaryauthorities, with the approval of the Local Government Board, to make regulations for thecompulsory notification and isolation of infectious cases. With respect to disinfection,ships and vessels in harbour were subject to the jurisdiction of the sanitary authority, in theway that houses were in mainland sanitary districts.

Within a decade or so, however, it became apparent that ships' captains and crews wereevading the regulations, because they resented the interference with their business andtheir liberty which sanitary regulation represented: a more precise definition of the portauthorities' powers was clearly required. In 1885, therefore, the Public Health (Shipping)Act explicitly extended the powers granted to mainland local authorities in 1875 in respectof infectious disease to the port authorities. These provisions enabled port MOHs tocleanse and disinfect where they considered it necessary to check the spread of infectiousdisease; to destroy infected bedding, etc.; and to remove those without proper lodging oraccommodation who were suffering from dangerous infectious disease to hospital. Portsanitary authorities could make regulations for the removal to hospital of infected personsbrought in by ships; and might impose a penalty for the exposure of infected persons andarticles, and for the letting of lodgings in houses where infectious disease existed. Theywere empowered to provide hospitals; to recover the cost of hospital maintenance frompatients; and to provide a gratuitous temporary supply of medicine and medical attendancefor poor persons in their districts.52The sphere of the port sanitary authorities' interest extended widely beyond their own

port limits, and contributed significantly to the overall success of the system. Apart fromsuch indications of foreign epidemics as were obtainable from the Registrar-General'sreports,53 careful attention was paid to the disease condition of ports of contact both athome and abroad. While something may be gleaned of the extent of such monitoring fromvarious sources, Henry Armstrong, the very able Medical Officer of Health for Tyneside,left a description of the activities of his department which probably reflects the practicescurrent in the great ports in the latter decades of the century. On Tyneside, extensive usewas made of the available printed sources of information. The medical and daily press, theShipping Gazette, and other journals were examined daily for reports of disease abroad. Alist of vessels bound for the Tyne from infected ports was kept, in which were entered thename of the ship, the date of her passing different ports on her voyage, and the expecteddate of her arrival. Ships on this register were visited without delay by sanitary officers onarrival. The sanitary officers routinely interrogated the captains of all vessels boarded for

5 Quarantine Act 1825 (6 George IV c. 78), secs. ix, xiv, xvi.52 Public Health Act 1875 (38 & 39 Vict. c. 55), secs. 110, 120-1, 124-6, 128, 130, 131-3. Public Health

(Shipping) Act 1885 (48 & 49 Vict. c. 35).5' The General Register Office kept a wary eye on foreign epidemics and regularly published statistics relating to

international disease incidence.

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information of infectious disease in their port of origin.54 It was this type of information-seeking, systematic monitoring and determined sifting of individual reports thatconstituted the country's most effective barrier against the import and dissemination ofdangerous infectious diseases in the years after 1885.

Early experience proved the need for such diligence. In his first six months as portMOH, Harry Leach discovered "pretty exactly" the quarters from which cholera might beexpected. Leach quickly became aware that London was being made a port of call for largeemigrant ships carrying parties of between 100 and 300 persons, which were hauled intodock and remained two or three nights in the port. These vessels and their freight oftencame from continental ports infected, or suspected of infection, with cholera. In July, forexample, the steamship Iris carrying Danish and Swedish emigrants brought twounsuspected cholera cases to London.55 Once the emigrants were settled in their emigrantlodging houses in Whitechapel (lodging houses with this especial function were to befound in Whitechapel, the City and St George-in-the-East) a serious outbreak occurred (28cases among 82 persons, with 8 deaths), and measures had to be taken to prevent thespread of the disease in the East End.56 Throughout 1873, cholera was more or lessprevalent in many parts of Europe, notably in Paris, Le Havre, Rotterdam and Antwerp,and during the autumn isolated cases were introduced into London, Liverpool andSouthampton from Hamburg, Rotterdam, Caen and Le Havre. In most cases the diseasedid not appear until the vessel had reached, or nearly reached, port. Leach's reaction wasto request all ship's brokers to furnish him with early notice of the arrival of emigrantships. In every case the MOH boarded such ships between Southend and Gravesend, andsystematically examined both passengers and crew, thus, he observed, not complicatingcommercial interests by detaining the ship.57

Even in 1873, Leach was plainly worried by the public health consequences of trade andtechnological progress. The opening of the Suez Canal and the extension of the worldrailway system yearly increased European contact with the East, where cholera wasendemic. In Leach's view, cholera was fast becoming endemic on the European continent,and London's "almost hourly communication" with the Baltic and Mediterranean portsplaced it in considerable danger.58 The Medical Department of the Local GovernmentBoard was equally worried: George Buchanan, Simon's successor, saw the behaviour ofcholera in Europe in the years 1865-74 as "of very evil omen", and instructed NettenRadcliffe, the Department's cholera expert, to examine the behaviour of the disease inEurope in these years.59 Leach had, however, already taken practical action. In 1874, hemade a European tour, visiting Le Havre, Antwerp and Rotterdam, as likely to provide fair

54 H. E. Armstrong, Port sanitarv administration on the Tvne, 1888, p. 1. Armstrong's description of hisprocedure in suspicious cases is quoted verbatim in Anne Hardy, 'Smallpox in London: factors in the decline ofthe disease in the nineteenth century', Med. Hist., 1983, 27: 111-38, p. 129.

ss MOHYR, Port of London, December 1873, pp. 11-12. See also PP 1874 xxxi, p. 6, fn.56 MOARLGB, PP 1874 xxxi, p. 5. See also MOARLGB, PP 1875 xl, Appendix 1: 'The diffusion of cholera and

its prevalence in Europe', by J. Netten Radcliffe.7 MOHYR, Port of London, December 1873, p. 12.

Ibid., p. 21.9 MOARLGB, PP 1875 xl, pp. 145, 153-368. British attitudes to foreigners-"wogs begin at Calais"-perhaps

reinforced this preventive suspicion of Europe as the source of cholera. For such attitudes see Colin Holmes,John Bull's island: immigration and British society 1871-1971, London, Macmillan Education, 1988, pp. 56-84,294-302.

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examples of the disease procedures of France, Holland and Belgium. His findings wererevealing. In the French ports, the "utmost secrecy and mystery" prevailed concerning theexistence of cholera, so that it was almost impossible to obtain an exact date, or to formcorrect conclusions. In the Belgian ports early news of epidemic cholera was not difficultto obtain, because all medical men were compelled to inform the secretaries of the sanitarycommissions of any occurrence of the disease. It was not considered advisable, however,to publish exact bills of mortality until the epidemic had ceased. In Holland, everythingwas apparently open. All physicians were under heavy penalty to inform the burgomastersof every case of cholera. The latter advertised the facts in the daily journals, informed thesanitary commissions, and quarantined affected houses by directing that a distinguishingcard be placed in the windows.60 Not surprisingly, Leach concluded that news of choleracases in Belgium and Holland was probably sufficiently reliable for preventive purposes;while shipping from France should always be treated with caution.

In spite of the efforts of very capable MOHs such as Leach and Armstrong in the majorports, the procedures for the detection of imported disease on incoming ships continuedunsatisfactory until the Shipping Act, 1885. In 1882, following representations from theUnited States that smallpox had been imported by immigrant shipping, the MedicalDepartment ordered an inquiry into the sanitary aspects of emigration and immigration,appointing F. E. Blaxall, a former naval man, to the task.6' Blaxall's report indicated anincreasing solicitude among the organizers of emigration for the health and comfort of theemigrants, and concluded that the quantity of preventable sickness spreading among suchpeople was relatively small. His report on the English port arrangements for detectinginfectious disease among arrivals from abroad was not so satisfactory. He pointed to a lackof any organized relation between the shipping companies and the sanitary authorities, andwas particularly anxious for the regular medical inspection of foreigners landing inEnglish ports. His suggestions for the improvement of sanitary practices in the ports andon shipboard, which chiefly concemed medical inspection of passengers and crews, werebased on his own experience of what was practicable in naval terms.62 Blaxall's inquirycertainly demonstrated the desirability of some form of medical control on what was nowa very considerable emigrant traffic: between 1820 and 1881, the number of emigrantspassing through British ports had increased tenfold, from 123,528 in the quinquennium1815-20 to 1,347,827 in 1876-81.63The cholera scare of 1883-4 compounded anxieties about port preventive organization.

Cholera broke out in the Egyptian port of Damietta in June 1883, and although theepidemic was over by September, the thousands of British troops stationed in Egypt led tograve fears of its importation.64 Netten Radcliffe had retired from the Medical Departmentbecause of ill health in 1882, and George Buchanan was conscious that the Department'scholera expertise had been seriously diminished. The regular official monitoring of theprogress and fluctuation of the disease in other countries had not been maintained, and

6() MOHYR, Port of London, June 1874, p. 62.61 MOARLGB, PP 1883 xxviii, p. 635, Appendix 14.62 Ibid., p. 636. Blaxall had been medical officer aboard HMS Caledonia when the ship experienced an outbreak

of cholera in June 1850. This was dealt with by medical inspection, isolation and treatment. Apparently similarpractices on other vessels suggest that this was a standard formula. Ibid., p. 789.

63 Ibid., p. 783.64 MOARLGB, PP 1884-5 xxxiii, p. 12.

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Buchanan felt unable to assess the likelihood of epidemic cholera spreading throughEurope from Egypt.65 Fresh prevention orders were issued to the port sanitary authorities,and a memorandum on cholera precautions distributed to other local authorities. Theimport of rags from Egypt was forbidden for the duration of the epidemic there, although itwas not known whether cholera had ever been imported in rags.66 These measures wererepeated in 1884, when epidemic cholera spread through France (causing between sevenand eight thousand deaths), Italy and Spain, and were supplemented by a hasty inspectionof the arrangements of 42 major port and riparian sanitary authorities. These were found tobe on the whole satisfactory,67 but the legislation of the following year did much toregularize practices in the various different authorities, establishing a common ground ofsanitary powers between port, riparian and mainland public health authorities.

Britain was fortunate in her cholera experiences in both 1872 and 1884. In the formeryear, John Simon recorded a handful of introductions: three at London, two at Liverpool,one at Southampton, and "at least one" at Swansea. Of these, the most serious was the Irisincident in London: Simon noted the danger to London as being "extremely great".68 In1884 Buchanan had only three importations to report: a troopship arriving at Portsea; and asteamship from Marseilles and an Italian mail steamer at Cardiff.69 In London, Leach'ssuccessor William Collingridge "scrupulously maintained" emergency precautions in1883 and 1884. All vessels arriving regularly direct from Marseilles received specialattention;70 and arrangements were made for the medical inspection of every vesselentering the river, in the event of any serious spread of the disease making such a courseadvisable.7' There can be little doubt of the efficiency of Collingridge's arrangements:they were described as "excellent" by Shirley Murphy, the highly critical MOH of theLCC.72

FREEDOM FROM CHOLERA AFTER 1867: PREVENTION AND PUBLIC CONFIDENCEThe failure of cholera to challenge English defences seriously in these years, as in

1857-9, lay only partly in the English preventive system. It was probably important thatno sustained epidemic wave of the disease reached Europe, and it was certainly significantthat it did not reach the Baltic ports. The challenge of imported cholera during the 1880s,as shown by the importations into the Port of London, was never very great (Table 1).The 1890s were, however, a very different matter. Between 1892 and 1897, 118 cases

were brought into the Port of London, of which 58 were introduced in 1895 (Table 1).73The final great European pandemic of cholera began in the spring of 1892. Two centres ofinfection were soon identified: Paris, where the disease broke out in April 1892, and

65 Ibid., pp. 12-13.66 Ibid., p. 12, Appendix A, nos. 14 b, 14 c. The memorandum on precautions against the spread of cholera, as

Buchanan admitted (p. 205), was almost verbatim that issued by Simon in 1866 and 1871.67 Ibid.68MOARLGB, PP 1874 xxxi, pp. 6-7.69MOARLGB, PP 1884-5 xxxiii, p. 204.70 These were the Peninsula and Oriental, Messageries Maritimes, and Trieste boats.7 1 Lancet, 1884, ii: 1 19.72 MOAR, London County Council, 1892, p. 26.7 In this year cholera cases were introduced from Buenos Aires, St Petersburg, and Kronstadt: MOHYR, Port of

London, June 1895, pp. 12-13; ii, p. 12.

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Table 1: CHOLERA CASES IMPORTED INTO LONDON, 1884-1901Year Cases Year Cases1884 - 1893 151885 - 1894 101886 - 1895 581887 7 1896 41888 2 1897 121889 - 1898 11890 - 1899 -

1891 - 1900 11892 19 1901 -

(Source: Annual Reports of the Medical Officerfor the Port of London.)

Russia. From these two centres the disease spread swiftly out across Europe.74 The worstoutbreak was at Hamburg, where between mid-August and mid-November 16,956 caseswere recorded, with 8,605 deaths.75 Even before the Hamburg epidemic, the Englishauthorities were on the alert. On 18 June, the Local Government Board medical officer,Richard Thorne Thorne, issued a memorandum in which he noted that on five of the sevenoccasions on which cholera had visited Britain, it had travelled by the Russianroute-across Russia to the Baltic ports, and from there commonly extending to the NorthSea and British Channel ports. It was from here that the disease had "several times"reached England, notably from Hamburg.76 In 1892 also, this linkage proved very clear:cholera broke out at Hamburg on 16 August; the first imported case was recorded inEngland on 25 August.77 Between 25 August and 18 October, 35 cases of cholera wereimported, but none extended beyond arrivals at the ports involved.78The warning of 1892 did not go unheeded. When the scale of the 1892 epidemic became

clear, the Medical Department conducted a hasty survey of the condition of the port andriparian sanitary authorities. The unsatisfactory arrangements which were found in manyports, and the continued prevalence of the disease abroad, prompted a more extensivesurvey in 1893. Known in the Department as the "Cholera Survey",79 this was published asthe Port and Riparian Sanitary Survey, 1895.80 Although when this survey was begun onlyone third of the 60 ports had a satisfactory and efficient sanitary administration,8' thearrangements for the medical inspection of vessels and persons-the crucial factor incholera prevention-was found satisfactory in all but five.82 In certain districts, however,

7 MOARLGB, PP 1894 xxxix, pp. xvii-xxii. Cholera had spread to Russia from British India, via Afghanistan,Persia and Turkestan in 1892-3." Ibid. The anatomy of this epidemic has been marvellously laid bare in all its aspects by Evans in Death, op.

cit., note 3 above.76 MOARLGB, PP 1894 xl, Appendix A, no. 16.77 Ibid., p. 8.7X Ibid.79 Ibid., p. 391.xo Port and riparian sanitary survey, PP 1895 lii.xl This was defined as including a competent and adequately remunerated MOH; sanitary inspectors; an

infectious disease hospital; disinfection facilities; adoption of the Infectious Diseases Notification Act 1889 andof section 125 of the Public Health Act 1875. In a third of other ports the administration was "lax and inefficient",the remainder falling in between. The lax ports were: Beaumaris, Boston, Chepstow (which had no foreign trade),Cowes, Dartmouth and Totnes, Falmouth and Truro, Harwich, Hayle, Ispwich, King's Lynn, Milford,Portsmouth, Preston, River Blyth, Sandwich, Scilly Isles, Wells and Yarmouth.

82 Port and riparian sanitarv survey, PP 1895 lii, pp. vi, viii.

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notably London, River Tyne, Hull and Goole, Southampton, Weymouth, Plymouth,Bristol, Cardiff, Bury-and-Cadoxton, Swansea and Liverpool, the medical inspectionarrangements were not only highly satisfactory, but were carried out by the MOHs withsuch devotion to duty, that the Inspectors concluded they must have "largely contributedto the marked success with which imported cholera was controlled at nearly all Englishports during 1892 and 1893".83 In 1893, cholera appeared in 62 localities, of which 15were metropolitan sanitary districts. There were 287 cases and 135 deaths; but in 42districts only single cases were known. These included 14 of the metropolitan districts. Inonly one metropolitan district was there more than 3 cases, and in only five districtsoverall was there a loss of more than 10 persons.84

Britain's freedom from epidemic cholera after 1866 had produced in many quarters theconfident belief that such epidemics were a thing of the past.85 Although the MedicalDepartment and local sanitary officers exercised extra vigilance and diligence inprecautionary arrangements during each fresh European crisis,86 England's limitedexperience of cholera between 1867 and 1892 encouraged public complacency. Duringthese years, generations grew up who had no personal experience of cholera epidemics,yet were aware of the disease as a constant threat abroad. As a result, the 1890s witnesseda marked discrepancy of emphasis between preventive action and public reaction to thethreat of a cholera invasion.The difference in public response to cholera between 1866 and 1892 reflects the growth

of confidence in the sanitary service, as well as a wider public interest in sanitary matters.There was a far greater response in anticipation of cholera in 1892 than there had been in1866. In 1866, cholera was no longer a novelty; its coming was beginning to be seen as acyclical event; and in that year also the previous eruption of rinderpest-the cattle plaguewhose progress across Europe had been scrupulously followed by the MedicalDepartment-absorbed public attention and distracted anxieties about cholera.87 At thistime, too, the Medical Department was privileged in its sources of information and in itsinterest in European sanitary matters. Before the major outbreak of cholera in England inearly July, the progress of the disease abroad had only been sparsely reported in the publicpress.88 English interest in cholera in 1866 was essentially insular in character. Theintellectual effects of advancing technology are very evident in the contrasting cholerareportage of 1866 and 1892-3: the development of the telephone and the telegraph, theextension of railway networks in Europe, and the emergence of passenger steamshipfleets, had revolutionized journalistic perspectives. By 1892, The Times, for example,carried lengthy and detailed reports from its special correspondents on cholera in Hamburgand Russia, while notices of the progress of the disease in distant parts of the worldstudded its pages. Readers of The Times would have been hard pressed to maintain anignorance of European cholera and the threat to England in 1892.

1-3 Ibid.84 The districts concerned were Grimsby (127 deaths), Hull (17), Ashbourne, Derbyshire (15), Cleethorpes (I 1),

and Clacton, Essex (I 1).8' Lancet, 1871, ii: 645; MOAR, Camberwell, 1883-4, 'Memorandum on cholera', p. 203.86See MOARLGB, PP 1884-5 xxxiii, pp. 12-14; Appendix A, nos. 14(b), 14(c); MOAR, Camberwell, 1883-4,

'Memorandum on cholera', p. 203; MOAR, Strand, 1883-4, Appendix, pp. li-lxxii; ibid., 1884-5, pp. 15-20.87 Norman Longmate, King cholera. The biographv ofa disease, London, Hamish Hamilton, 1966, pp.2 12-13.88 The Times, for example, carried only a bare handful of such references between April and July 1866.

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Journalistic interest in the prospect of cholera in 1892 seems to have generated a greaterpublic awareness of that prospect than in 1866, among the educated classes at least. Norcan it be doubted that the activities of the preventive authorities contributed to thisawareness: already in the summer of 1892, they were taking "infinite pains" to make theirwork efficient.89 Yet the zeal of the sanitary authorities in this respect may also have beencounter-productive. Although there was no indication of any "epidemic tension" or panicover the threat of cholera,90 there were those who considered that this might be the resultof the sanitary authorities' energetic reaction. On 5 September 1892, The Times carried aletter which sought to remind the general public that "the greatest ally of cholera is fear".The writer pointed to the differences in scale between epidemic cholera in the East-adeath-rate of 559 per 10,000 at Damietta in 1883-and in England: death-rates of 30, 11and 7 per 200,000 in the "epidemics" of 1849, 1854 and 1866. He thought it notunreasonable to assume that if cholera reached England that year, mortality would be lessthan in 1866, and recommended going about one's own business, "in the ordinary way":

This I venture, with some experience to say is a safer course than being frightened intoexceptional precautions, preventives, and remedies.9'

Nonetheless, cholera provoked an extensive reaction in 1892. The Times leader of 5September, while applauding the "foresight, zeal and activity" of the sanitary authorities,elaborated the argument by pointing out that sanitary offenders were a relatively smallproportion of the community. In a passage remarkable for its unscientific logic, the paperurged the authorities to temper zeal with discretion, to take pains to do good, but only bystealth.

The class ... likely to grow nervous under the steady shower of warnings and exhortationsnow being poured out upon them is considerable, and the importance of the fact ismanifest when it is remembered that fear ... is the most potent ally of epidemic cholera. . . Provident fear in their [the authorities'] breasts may be the mother of safety, but shouldit spread to those under their charge it can only sap the spirit of the garrison and makethings easy for the enemy.92

Behind these remonstrations may be detected a whole spectrum of social and economicfears; no longer that cholera itself should damage the established order and prosperity ofthe country, but that the anticipation of cholera should do so.

It was evidently a potent anxiety. By the following spring when the sanitarians werefully expecting a major outbreak of the disease, Arthur Shadwell, The Timescorrespondent in Germany and Russia the previous year, complained irritably of theattitude of the press, which was encouraging the widespread popular belief that cholerawas always more or less present on the Continent, and that the outbreaks at Hamburg and

9 The Timnes, 3 September 1892.90 Ernest Hart, 'Cholera and our protection against it', Nineteenth Century, 1892, 188: 650; Metropolitan

AsYlums Board annual report (henceforth MABAR), 1893, p. 264." The Times, 5 September 1892. For the preventive riposte to this letter see Hart, op. cit., note 90 above.92 The Times, 5 September 1892. The paper went on to note that "sensational statements" had been made, which

received "a certain degree of support from the fussy action of local authorities here and there".

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Paris presented no greater danger than those successfully encountered on many previousoccasions, "with the laudable but superfluous intention of allaying an alarm which doesnot exist".93 Twenty-seven years of immunity from epidemic cholera had done their work:for most Englishmen, it seems, its continued existence on the Continent was a furtherillustration, if need be, of superior English standards of hygiene, and generally greaterdegree of civilization.

For informed sanitarians, however, the public optimism of 1892 was misplaced; withcholera at Hamburg, the danger to England must be considered grave. Arguments infavour of quarantine were again, rehearsed.94 The Medical Department deployed Dr Barryto monitor the diffusion of cholera through Europe, and by the late summer of 1892 wasissuing precautionary advice.95 New measures were taken to control the passage ofemigrants from the Baltic, and a Cholera Order was issued on 6 September.96 Meanwhile,the Lancet, manifesting almost hysterical alarm, lauded the new controls on the passage ofemigrant Russian Jews, and urged extensive attention to preventive measures.97 TheMetropolitan Asylums Board hastily appointed Arthur Shadwell to supervise emergencyarrangements in case of an epidemic in London, while the city's local authorities andmedical officers rehearsed their cholera provisions and prepared stocks of posters.98Similarly extensive precautionary arrangements had been made in 1884,)9 but Shadwellconsidered in retrospect that the country had never been exposed to such danger fromcholera since 1866. 1°°

It is plain that neither in 1884 nor in 1892-3 were the preventive authorities taking anyrisks. In both these pandemics elaborate arrangements were made to deal with anyoutbreak of cholera in London, and the preparations in London in 1892, in particular,highlighted the similarities and contrasts in the approach of professionals and public to theprospects of a cholera epidemic. There was no panic, but whereas the public healthauthorities took the epidemic threat seriously, and prepared accordingly, public attentionwas not seriously engaged. Indeed, a whole chaotic, preventively anarchistic spectrum ofpopular preoccupations and beliefs was ranged against the professional cohesion of thepreventive services. While the newspapers were anxiously peddling the calming view thatthe country was in no real danger of cholera, very real fears were evidently entertained bysome sectors of the population.'0' These were fuelled by the reported handful of cases,

9' MABAR, 1893, part vi, p. 264.94 See Thorne Thorne's explicit rejection of quarantine, MOARLGB, PP 1894 xxxiv, pp. xxiv-xxix. British

practice at this date involved the examination of vessels on entry to the port, and removal to hospital of sickpassengers and crew. Ships in port were then inspected daily for the duration of the incubation period of thedisease as recognized at the time, i.e., for up to 15 days.

9" MOARLGB, PP 1894 xxxix c 7412, Part III, pp. xvii-xxx; Appendix 12: 'Report by Dr Barry on the origin andprogress of the western diffusion of cholera during the year 1892'; MOARLGB, PP 1894 xl, Appendices 14-20.

9' MOARLGB, PP 1894 xxxix, Appendix no. 16.7 Lancet, 1892, ii: 591."x Newington Vestrv minutes, 21 September 1892; MOAR, St Giles, 1892, pp. 74-9; MOAR, Mile End Old

Town 1892, pp. 11-12; MOAR, Plumstead, 1892-3, p. 99; Camberwell Vestrv anniual report, 1892-3, p. 245;1893-4, pp. 252-3.

' E.g. MOAR, St George-in-the-East 1884, p. 43."x'MABAR, 1893, part vi, p. 264. See also Lancet, 1893, ii: 1071."" See, for example, Newington Vestry annual report, 1893-4, p. 30.

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notably by the death of a cleaner at the House of Commons from undoubted Asiaticcholera in September 1893.102 On the other hand, Arthur Shadwell reported sourly on thelack of public co-operation encountered in his attempts to establish the metropolitancholera service: "In this respect our enlightened British democracy has shown no moreintelligence than the benighted peasantry of Russia".'03

British shortsightedness and obstinacy manifested itself especially over the siting of theambulance stations. In part, this was perhaps a reflection of the general attitude towardsinfectious disease hospitals ("not in my back yard"), but Shadwell, who took an educatedinterest in popular politics, hinted at deeper reasons. He eventually managed a fairlysatisfactory provision of ambulance stations throughout the city, except in Rotherhithe.Here only two stations could be arranged, the Workhouse Infirmary and the MetropolitanAsylums Board's own South Wharf. Both Shadwell and the Medical Officer of Health,Josephus Shaw, made repeated attempts to obtain more, since they considered Rotherhithea prime cholera target, and it was a district of many suitable yards and other places. Theowners of these premises were, however, resolute in declining permission for their use,

on the ground that the presence of a cholera litter would be seized by the labouragitators ... as a pretext for causing trouble among the working men.'04

It is a notable feature of the list of cholera stations that less than a dozen of the 133 appearto have been privately owned establishments, rather than local government, Poor Law,Police or hospital premises.'05

Britain was in many respects fortunate to escape cholera in 1892-3. Vigilant andwell-prepared sanitary authorities might nonetheless have been hard-pressed by anyconcerted assault of the disease. Symptomless carriers of cholera were a factor which nopreventive action could hope to counter on any significant scale, while the dangersassociated with the freedom of travel through the Channel passenger ports was wellrecognized.'06The outbreak at Grimsby and Cleethorpes in August 1893, in which 127people died, and from where cases were traced to twenty-six towns in the Midlands andthe North, from Gloucester and Hereford in the west to Newcastle-upon-Tyne, gave clearwarning of the consequences of inefficient sanitary supervision and poor sanitarycircumstances.'07 The serious prevalence of typhoid in the valley of the Tees meanwhile

"02 For this case see MOARLGB, PP 1894 xl c. 7539, Appendix no. 6, pp. 123-4: 'Report by Dr DeaneSweeting on a fatal case of cholera in Westminster'; ibid., Appendix 7, pp. 125-6: 'Memorandum as to advicegiven with regard to the disinfection of certain portions of the House of Commons' by Dr S. MoncktonCopeman. According to Shadwell, attempts were made to hush up or garble the truth of this event: MABAR,1893, part vi, p. 267.

1'-3 MABAR, 1893, part vi, p. 264."'' Ibid., p. 261-2." Ibid., part vi, 'Report on the Board's cholera arrangements', Appendices A and B.I>6 Dr Yunge-Bateman, 'Cholera from a passenger port point of view', Public Health, 1892-3, 5: 261-2;

aincet, 1893, i: 424.1"7 For this outbreak see MOARLGB, PP 1894 xl, Appendix no. 2, pp. 47-88: 'Report on cholera in 1893 in

Grimsby and Cleethorpes', by Dr Reece. Preventive anxieties were particularly sharp on this occasion becauseGrimsby fish were sold throughout the country, while Cleethorpes was already a thriving pleasure resort. TheGrimsby cockle beds were known to lie beside the local sewer outfall: Lancet, 1893, ii: 636.

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illustrated that the diffusion of cholera by water was still a possibility.'08 Once again,however, seasonal and geographical factors seem to have been significant in preventingdisaster.The most serious epidemic of cholera in Europe in 1892 was that at Hamburg; and from

Hamburg, as experience showed, lay the greatest danger to England. Detailed examinationof the circumstances of 1892 suggest the narrowness of England's escape. The Hamburgepidemic broke out on August 16, rushing to a climax in the last fortnight of August andthe first week of September, and thereafter declining until it disappeared at the end ofOctober. '09 The timing of the epidemic outbreak at Hamburg was of critical significancein determining whether or not cholera would issue a major challenge to England across theNorth Sea; and in 1892, cholera arrived in Hamburg too late. By 25 August, when the firstimported case from Hamburg was recorded, the year was already past the season at whichcholera most readily found foothold in the country."0 The possibilities of a majorepidemic escalation were small by the time the disease reached London in earlySeptember. Secondly, the European ports most seriously affected by cholera, such asHamburg and Antwerp, were distant enough that infected persons could be expected to beshowing typical symptoms of cholera on arrival, and early recognition of the disease bythe port sanitary medical staff was much easier. ''

Despite the alarm caused by Hamburg, the greatest possiblity of danger, as far as theEnglish preventive authorities were concerned, was not in 1892, but in the following year,since cholera in the past had generally reached England in the second year of its Europeanvisitations."2 In 1893, however, the disease made no appearance in Hamburg beforemid-September,"3 although it was active during the spring and summer in the LowCountries, France and elsewhere in Germany. The first imported cases arrived onTyneside from Nantes as early as 25 June; the infection at Grimsby, which had begun inearly August, was traced to Antwerp.'4 Once again, these ports were at a sufficientdistance to facilitate the detection of cases, except, as the case of Grimsby proved, wherethe city and port sanitary authorities were inexcusably negligent. The outbreak at Grimsby,and its minor consequences, are evidence of the effectiveness of the wider sanitaryorganization, for there was no diffusion of the disease in the twenty-six towns to which theinfection was carried from Grimsby and Cleethorpes. It may be, nonetheless, that Englandwas once again protected from a more severe onslaught of cholera by the climatic factor.The summer of 1893 was one of those dry, hot summers that characterized the 1 890s, andwhich was probably inimical to the prolonged survival and disseminative properties ofcholera. As Arthur Shadwell pointed out, the wide geographical spread of cholera inEurope during 1893 was accompanied by a comparatively low mortality, and althoughincreased knowledge and improved sanitary conditions might have had some part to play

1' Lancet, 1893, ii: 1071, 1144, 1198. For the Tees Valley problem see PP 1893-4 xlii c 7054, pp. 261-528,'Supplement in continuation of the report of the Medical Officer for 1891'; 'Enteric fever in the Tees Valley',Lancet, 1893, ii: 1198.

"' Evans, op. cit., note 4 above, p. 293, Fig. 9.""1MOARLGB, PP 1894 xl, p. vii; Lancet, 1893, ii: 445." ' Ibid.112 Public Health, 1892-3, 5: 12.113 Evans, op. cit., note 4 above, p. 490."4 Lancet, 1893, ii: 445; MABAR, 1893, part vi, pp. 266-7.

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in this, it was hard not to think that the exceptionally dry season had more to do with it. 1 15In England, for example, the greatest diffusion of the disease, and nearly all the cases,occurred north of a line from the Wash to the Severn, in that part of the country leastaffected by the drought.' 16The incursions of 1893 represented the last extension of cholera into the English

mainland. In 1894 the disease was severely epidemic in Russia, and Germany, Belgium,Holland, Hungary and Turkey were also affected. In France, however, cholera was on theretreat, and by 1895 it was waning in Russia, and had retreated still further from WesternEurope, into Galicia, Turkey, Egypt and Morocco. It was not without its old pandemicpowers, however, for when in February 1896 Russia was finally declared free of cholera, asevere visitation was beginning to make itself felt in Egypt. '1 7 Past experience had by nowso reinforced the confidence of the British public health authorities in their preventivesystem and in the modified danger which cholera in the Near East presented, that theEgyptian outbreak raised little concern. By 1898, cholera had disappeared from the list ofthe Medical Department's current anxieties, to be replaced by bubonic plague."18

If the larger movements of cholera were to some extent determined by the vagaries ofseason and climate, there is no doubt that sanitary circumstances and personal habits ofcleanliness were major elements assisting its spread and influencing the locality ofepidemic outbreaks. Recognition of these two sets of factors, within the constraint of anational maritime policy of freedom of trade, and in association with an internalpreventive policy of detailed isolation for infectious disease, formed the basis of theEnglish defence against cholera in the last three decades of the nineteenth century.Through the medium of the International Sanitary Conferences, and later of theInternational Conferences on Hygiene and Demography, the premises of English policywere given wide publicity on the European Continent, and came to be generally acceptedwith respect to the limitation of cholera dissemination by shipping in the last years of thecentury.' 9 Britain's sanitary surveillance of international shipping comprised the finalplank in a national preventive system which was widely admired by contemporaries-itwas, the Finn Alfred Palmberg noted, the most complete and precise in the civilizedworld- and Britain's success at excluding cholera after 1866, like her falling death-ratesfrom tuberculosis, was regarded as proof of the superiority of that system.'20

While circumstances and good fortune certainly played their part in preserving Englandfrom epidemic cholera in the last three decades of the century, the systematic developmentof her sanitary defences, and the policies of a forward-looking central medical departmentsupported by a dedicated local preventive network, appear to have been critical in holdingrepeated cholera attacks at bay. The calm with which the general public faced the greatest

MABAR, 1893, part vi, p. 269.l6 Ibid.17 MOARLGB, PP 1896 xxxvii, p. 316; MOARLGB, PP 1897 xxxvii, p. 21; MOARLGB, PP 1898 xl, p. 18."8 MOARLGB, PP 1899 xxxviii, pp. 30-8; ibid., Appendix A, no. 18: Dr Bruce Low 'On the diffusion of

bubonic plague', pp. 257-318.'9 Hauser, op. cit., note I above, p. 538.21 Alfred Palmberg, A treatise on public health and its applications in different European countries, London,

Swan Sonnenschein, 1893, p. 3, cited in Anne Hardy, 'Public health and the expert: the London medical officersof health 1860-1919', in R. M. MacLeod (ed.), Government and expertise: specialists, administrators andprofessionials, Cambridge University Press, 1988. See also the speech by Pierre Brouardel published in PublicHealth, 1899-1900, 13: pp. 797-8.

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of these apparent threats in 1892-3 was partly the result of improved domestic sanitaryconditions, but was also based on confidence bred of past experience, on an improvedunderstanding of the means by which the disease was transmitted and on broad popularignorance of its epidemiological behaviour. It was those who remembered the epidemic of1866 who were aware of the dangers of indifference, and who knew, as did Ernest Hart,that epidemic cholera was a disease which "struck down masses of the population inlimited localities", that still feared its import in 1892. 121 If the mystery of cholera had beenexploded by the end of the nineteenth century, familiarity with its causes and conditionsdid not enable the preventive establishment to view its entry into the country withequanimity.

121 Hart, op. cit., note 90 above, p. 65 1.

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cholera, quarantine preventive system, …...cholera, quarantine andthe english preventive system...

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